| Abstract: | Background: Thisstudyaimstoevaluatethelong-termeffects on glycemic control for a domestic diabetes care program focusing on case management and to discuss the challenges in promoting the quality of diabetes care in Taiwan. Method: Werandomized(communityclinic-based)1060study subjects recruited from the 2003–2005 DMIDS (Diabetes Management through an Integrated Delivery System) project into an intervention group (n=789 from 27 clinics) and a control group (n=271 from 7 clinics). A quarterly self-care and nutrition education program was initiated by qualified case managers for the intervention group, while usual care was given to the control group. The intervention program was provided from 2003 to 2007. HbA1c was measured once every 6 months for each participant until 42 months after recruitment. The difference in HbA1c between two groups was analyzed both as a whole and after participants were stratified into 3 classes according to their baseline HbA1c: <7%, 7–9%, and >9%. Multivariable mixed model analysis was performed to assess the intervention effects on HbA1c control. The covariates adjusted in the models included age, gender, education, DM duration, baseline HbA1c, and region. The clinic was treated as a random effect. A two-sided P value <0.05 was considered statistically significant. Result: HbA1c in the intervention group had remained significantly lower than that in the control group since sixth months after recruitment, and the intervention effects were estimated to be capable of lasting for at least 3 years. The HbA1c levels checked at an interval of 6 months during the period from the 6 th to the 36 th months read 7.7, 7.8, 7.9, 7.9, 8.0 and 8.0% for the intervention group and 8.4, 8.6, 8.5, 8.6, 8.9 and 8.8% for the control group. Subgroup analysis found the 7–9%, and >9% classes of the intervention group marked with a significantly lower HbA1c for 3 years, as compared to their counterparts in the control group, However, in the <7% class, the difference between the two groups failed to reach significance. Conclusion: The current study shows that the case management of the pay-for-performance (P4P) diabetes care program in Taiwan is effective in improving glycemic control for at least 3 years. However, previous studies indicated an association of poverty with not only higher diabetes incidence but inequality of diabetes care in Taiwan in spite of the universal health coverage. Sicker diabetes patients were observed to be less likely to enroll in the P4P diabetes care program. More studies on the cost-effectiveness of the program and health policy reform are needed to optimize diabetes care in Taiwan. |
